Thursday, March 31, 2011

Well it certainly is long overdue for me to chime in on what most certainly started as a small blog about why my friends and I enjoy Family Medicine, yet has exploded into one of the best medical blogs around.

I was driving into work this weekend listening to the radio and heard one of the fancy adds that our hospital has been airing over the last few years of it's "Good People, Great Medicine" campaign. The add was talking about getting results for a patient recovering from a heart attack. Around central PA, this patient is far too common. And listening to the add brag about how quickly this patient got to the cath lab, how great our HVICU is, or even mentioning the fact that our hospital has a great cardiac rehab program I could only think of one thing: why did this guy have a heart attack in the first place? And that's when I heard it: _____ _____ Heart and Vascular Institute (name of institution left out intentionally).

It got me thinking, what is in a name? Why do our ivory tower, academic, tertiary care health centers insist upon having things like Heart and Vascular Institutes, Eye Institutes, Cancer Institutes, and well the list goes on. Calling something an "institute" to me makes it sound like a place where great minds gather to think about things and work on the cutting edge of science and technology. And I can only help but think that our patients are thinking the same thing. Why go talk to Dr. Smith the cardiologist at his solo practice when you can go to the Heart and Vascular Institute? Why settle for the ordinary, when the top of the line is right next door?

But are the cardiologists who work in our Heart and Vascular Institute any better than the other physicians at our hospital? Is the care we give to patients post MI any better than the care we give to the nursing home patient with pneumonia or the 15 year old with appendicitis, or even the 4 year old with type 1 diabetes. I would hope not! So what then earns you the distinction of being named an institute? Can anyone be called an institute?

This brings me to the question I asked driving in to work: why did this guy have a heart attack in the first place? Is it because his BMI was 28? or his LDL 183? or his BP 155/85? Is it because he, like many men, didn't routinely get a physical by his primary care doctor? He sounded all to pleased to come to our Heart and Vascular Institute, because in his mind it was the best there was, but what if our hospital had a Family Medicine Institute? or a Preventative Care Institute? Or maybe more to the point a "We keep you from getting sick in the first place Institute." Well maybe that one isn't so easy to say. But I think my point is clear - what if we in Family Medicine took advantage of the buzz words that seem to draw patients in to these tertiary care clinics and used it to bring them to our primary care clinics first? What if we finally owned up to the fact that what we do is just as state of the art and cutting edge: after all, we keep people from getting sick in the first place.

Sunday, March 20, 2011

I recently started a subscription to the American Family Physician and, today, I received my March 1st issue in the mail. Spending some time reading it this weekend, I was once again struck by the overwhelming prevalence of drug advertisements. Out of the 143 pages of this issue, 81 pages are made up of ads (the majority of which are pharmaceutical company ads... there are a few pages of AAFP and classified employment ads). That is a whopping 56.6%.

Now, I didn't choose American Family Physician just because it's the only journal with a ton of drug ads. It just happens to be the one I read regularly. When I pick up copies of NEJM, JAMA or in my medical school library, it's the same. I may not even want to be looking at the ads - but, reading the article on "Systemic Vasculitis," I remember that Namenda can be used for Alzheimer's Disease because I flipped by that page. I also remember that Lexapro is "proven" to be effective for adolescent depression - that's on the back cover.

In 2008, Dr. John Abramson, a family physician at Harvard (this is amazing in itself!) published Overdo$ed America, a book that describes the growth and power of the pharmaceutical company industry in the United States. Up to the 1970s, the majority of pharmaceutical research occurred in universities and other academic settings, funded by NIH grants. As government funding decreased over the next few decades, private drug companies filled the gap. At first they funded trials in university settings and then they gradually privatized the operations as well. In 1991, 80% of commercially sponsored clinical drug trials were run by universities and academic medical centers. In 2000, this number has dropped to 33%.

What's wrong with this picture?

The problem is that, all too often, physicians end up prescribing drugs that may not necessarily be evidence-based but advertisement-based. Family physicians and primary care doctors particularly fall prey to this since they prescribe for the broadest spectrum of diseases and have to be knowledgeable about the plethora of drugs available now.

Remember Vioxx? Used widely by PCPs to treat osteoarthritis and dysmennorhea, Vioxx was found to be associated with increased adverse cardiovascular problems including MIs and strokes. In the 5 years it was available on the market, over 80 million people were prescribed it.

But we continue to prescribe drugs, especially in the United States, that lack sufficient evidence of benefits that outweigh risks. Take for example ezetimibe. Ezetimibe is the most common second line drug for cholesterol (after statins, which are first line). There are purported fewer side effects than that of other second line drugs - however, clinical trials to demonstrate improved CV outcomes and mortality outcomes are still underway.... with no results published to date. Let's compare prescription drug rates of ezetimibe in Canada and the USA.

Canada: in 2002, 0.2% of those on a lipid-lowering drug were using ezetimibe; in 2006, 3.4%

USA: in 2002, 0.1%; in 2006, 15.2% (NEJM 2008; 358:1819-1828)

We continue to medicate our patients when we don't know if there are any beneficial outcomes.

So what can we do about this?

Don't rely on a drug advertisement or word-of-mouth when prescribing drugs. Check out a evidence-based source.

Advocate for national changes in the way that drugs are approved and distributed.

Advocate for changes in drug advertising!

We need to do this for our patients - and for the future of primary care.

Thursday, March 17, 2011

Disclaimer: This post will be an evolving post that will change throughout the course of the week as results and statistics are released for the match in regards to family medicine.

Well, medical students - the day is here! NRMP Match Day - a day that brings us full circle to US Grads matching into residency programs throughout the country. It all started back in December with the military match, then continued with early match, the Osteopathic match, and now the NRMP match.

Military match stats this year had family medicine listed along with peds, ob, surg, and ortho as the most competitive for medical students participating in the military match.Osteopathic match: "Primary care specialties of family (medicine) saw a 15% increase and internal medicine saw a 28% increase. Family (medicine) was the largest matched specialty with 373 positions filled."

This year, 172 more students chose family medicine - 2,576 family medicine positions were filled out of 2,730: a fill rate of 94.4% - impressive when taking into account that 100 more positions were available for family medicine vs. last year. Of the 2,576 candidates who selected family medicine, 1,317 of them are U.S. medical school graduates - this as a result of 133 more US Grads choosing family medicine this year (7.9% of US students chose family medicine last year vs 8.4% this year).

For the second year in a row, more U.S. medical school seniors will train as family medicine residents, according to new data released today by the National Resident Matching Program (NRMP). The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010.... Among primary care specialties, family medicine programs continued to experience the strongest growth in the number of positions filled by U.S. seniors. In this year’s Match, U.S. seniors filled nearly half of the 2,708 family medicine residency slots. Family medicine also offered 100 more positions this year.

Although the Match results are encouraging, student interest, however, is still not at the level it needs to be. Although the match rate in family medicine among US medical school graduates has increased, the majority of positions offered and filled in the NRMP, especially among US graduates, continue to be in non-primary care sub-specialties. In its 20th Annual Report “Advancing Primary Care”, the Council on Graduate Medical Education (COGME) affirms that the US physician workforce needs to be made up of "at least 40% primary care physicians" to ensure the nation's health, health care access, health care expenditures and health outcomes for the future.COGME projects that to reach this 40%, 63,000 additional primary care physicians are needed. If health reform succeeds in increasing the number of insured individuals, more than 100,000 additional primary care physicians will be needed.The number of students entering family medicine is most reflective of the future physicians who will provide primary care for adults in the future. The vast majority of internal medicine residents sub-specialize; only 2% of students entering an internal medicine residency choose to do general primary care after residency graduation in one study.

“This year’s results mark the second consecutive year of increased interest in family medicine,” Goertz said. “Although several factors likely contribute to the increase, we believe an important element is recognition that primary care medicine is absolutely essential if we are to improve the quality of health care and help control its costs. Of course, sustaining this interest will require continuing changes in the way America pays for and delivers health care to patients.”

“Primary care has become much more visible as a result of the discussion about improving our health care system,” he said. “More people understand that if we’re to have high quality care at a controllable cost, we need to rebalance our system on a foundation of primary medical care.Add in the heightened awareness through activities of the Family Medicine Interest Groups, and students began to understand that family physicians will be able to practice the kind of medicine they envisioned when they decided to become a doctor.”

"This is good news for internal medicine and adult patient care in the U.S.," J. Fred Ralston Jr. MD, president of the American College of Physicians (ACP), said in a statement.
The organization appeared guarded, however, adding that the primary care work force still has "a long way to go" to meet the needs of an aging population with various chronic diseases."We're cautiously optimistic and hope that the positive trend continues, but the U.S. still has to overcome a generational shift that resulted in decreased numbers of students choosing primary care as a career," Steven Weinberger, MD, executive vice president and CEO of the ACP, said in the statement

Tuesday, March 15, 2011

The image and role of the family physician in American medicine has shifted from the house-calling doctor with a black handbag to the integrated coordinator of patient care. Despite this, reimbursement remains largely unchanged, with fee-for-service the dominating payment structure. The modern health care climate demands a robust health policy strategy that restructures these outdated reimbursement schemes. Realigning appropriate payment would address issues with ongoing care for patients with chronic conditions and continuity of treatment. Further, restructuring reimbursement would have an effect to revitalize interest and incentive for medical students to enter the field.

Primary care physicians (PCPs) are recognized as family physicians, general internal medicine practitioners, general pediatricians, and obstetrician/gynecologists. As a group, PCPs are often the first point of physician contact for patients with new health issues. PCPs typically serve as coordinators of comprehensive care, and as mediators between specialists. Studies show that one-fourth of Medicare beneficiaries sees an average of 13 physicians each year, and fills 50 prescriptions in that time. PCPs are the primary point for consistent medical contact for these patients – the proverbial glue that holds the pieces together. These are the doctors that are at the front lines of medicine, but who also work in the trenches of prevention and management of chronic care.

While new models for health care are continually considered, such as the Accountable Care Organization (ACO) and the Patient-Centered Medical Home (PCMH), the common theme among all is the central role of the primary care physician. The fundamental key lies in placing the PCP as the coordinator for a patient within a system of care. This is particularly important in rural or underserved areas. PCPs are called not only to treat patients at point-of-care, but also to manage and facilitate physician extenders.

One of the foundational problems in fee-for-service is that it essentially encourages payment for sickness. Through the course of a year, a diabetic patient may see a PCP for a total of two hours. Yet that same patient has to manage their disease for 8,765 hours in that year. The PCP is reimbursed for the sum of two to three visits of point-of-service care, but the disease is ongoing. This would be akin to having a leaky kitchen faucet and asking a plumber to come look at it twice a year, paying for those two visits, but never having the leak quite fixed. While it remains impossible to completely “fix” a diabetic patient, reimbursement must be restructured to account for ongoing and chronic care. The existing plan provides compensation for volume of care. This model must be updated to consider compensation for counseling, diagnosis, and continuity. Moving away from fee-for-service would shift the perspective of reimbursement from one that pays for sickness to one that encourages payment for healthiness.

Finally, shortages in primary care medicine, long considered the gatekeeper of health care, are now threatening national access to care. Studies show that over 60 million Americans, or nearly one in five, lack access to primary care due to shortage in their communities. Meanwhile, only 8% of the nation's medical school graduates enter family medicine. This compares to 14% of the same graduates in 2000. Restructuring reimbursement would have a profound impact on the incentive for students to enter the field of primary care medicine.

It is often said that an ounce of prevention is worth a pound of cure. This analogy certainly has profound implications for our modern health care system. Primary care physicians, the vanguards of preventative medicine and caretakers of chronic disease, should be reimbursed for the broad level of responsibilities they conduct. Our nation must undertake a sincere evaluation of our reimbursement models and engage in the development of a more robust payment scheme for primary care physicians.

Saturday, March 12, 2011

It is our pleasure to have the opportunity to make his publication our first official cross-post on the Future Of Family Medicine Blog!

We have made this post a "page", making it accessible from any post that you may be reading as a reminder of our dedication to the continuing advocacy and promotion of awareness for the primary care workforce that our patients and country needs.

As medical students committed to family medicine, we are allies in the #FMRevolution and look forward to the upcoming development of an official Family Medicine Revolution interactive website as well as other projects that are created.

The status quo is not ok - we will not let others determine our roles as primary care physicians... Now Is Our Time. Vive la résistance!

Tuesday, March 8, 2011

Every one of us who practices family medicine has had to defend our chosen profession against a myriad of antagonists.As mentioned in the post ‘Family Medicine is a Waste of Your Talent,’ we are sometimes told that we are too smart to pursue family medicine.Other topics range from salary comparisons between specialties to scope of practice.I’ve been told on many occasions that I should specialize for many different reasons but am rarely commended for choosing primary care.Luckily, most of us are unphased by such comments.However, I believe that there are students who are pulled from primary care because of what I like to call the hazing process.I conducted a small but national scale survey of students, residents, and attendings to see how others handled this phenomenon.

Students who are unwaveringly committed to primary care are not influenced.Students who are unsure about what they want to do are highly susceptible to take the criticisms as fact and start to question their dedication to primary care.These two findings did not surprise me as I had seen many students fluctuate in and out of favor of family medicine over the past four years.What I did not expect to find is the attitude that the established, experienced family docs had.As a whole, they vastly underestimated the effect this process has on students’ career choice.Most of the responders were academics who I thought would be more tuned in to the problem, but they seemed to have been in the ‘immune’ group when they themselves were students and thus, assume that everyone knows the negative comments are not well-founded.One felt that it is simply unprofessional to speak ill of another field while another described the issues as ‘tired old clichés’.I had a lengthy discussion with another physician who felt there must be some difference between those students who are susceptible to changing their interests at the suggestion of a peer or authority figure versus those who are not.

One thing stood out to me about the wavering group of students.They all had questions.They wanted to know if the things they were hearing were true.They’re not!Family medicine trained physicians work as hospitalists, they see plenty of kids (if they want), they do procedures (sometimes even operative ones like appendectomies), and they are not poor.Even being one of the lower paid specialties with an average income of $150,000, it still ranks in the top 5% income bracket in the US.And according to the 20th COGME report, the U.S. is going to have to increase its recruiting efforts because we will need so many more family physicians in the coming years.So the potential for employment is about to skyrocket as explained in the post ‘Analyzing COGME: Increase the Number of Primary Care Physicians.’Family medicine will be growing faster than any other specialty.

America wants more family physicians.When I meet people (who don’t work at the hospital) who ask me what my specialty is and I have the pleasure of saying family medicine, I am encouraged.At my local farmer’s market the vendors thank me for being interested in rural primary care.I met some people cross-country skiing who hugged me when I said family medicine. I often ask people how far they have to drive to see a doctor, where the nearest pharmacy is, or if there is a community health center in town.This facilitates a conversation about what primary care providers do for a community, even if the person doesn’t necessarily have a well defined perception of what a family physician is…and they like what they hear.

So my recommendation to students who are undecided is to take your concerns to the family medicine departments at your schools or to private practice family physicians in your communities.Not only can they first-handedly dispel these myths but they will hear loud and clear that family medicine needs to be promoted.If our students don’t know the truth about the potential within the field, how will our community members?If you ask someone what they would like from the medical system they will describe a family physician in a patient centered medical home. So let’s spread the word that it already exists and that we are happily working there by doing the following:

1.Help stop the hazing by confronting the hazers with data and confidence.Be proud of your choice because you will help lower health care costs and provide a much needed service to your community.

2. Get involved with your family medicine interest group, the AAFP, or your state chapter where you will be exposed to resources and peers because even if you are the only student in your class who is interested in family medicine, there are thousands around the country.

3.Attendings and residents need to reach out to students and be more active in representing the field of family medicine.

4. Do what you love and do it well. Explain why primary care is so important to your family members because the ultimate reward is choosing the right career, not making the most money.

Match Day is once again upon the world of medicine, and we are eager to outline and track updates to 2012 match results for Family Medicine...

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